Mapping and the Trolley Problem [1]

I meet Ivan Gayton at the Schiphol Airport in Amsterdam after six months of communication and planning; we’re boarding our KLM flight to Sierra Leone, West Africa. It is Wednesday, the seventh of June. We have decided to name the project West Africa Motorcycle Mapping 2017. Characteristically, Gayton quickly launches into a typical wide-ranging discussion that is mostly lecture. I’m new to mapping, but I’ve had enough of an introduction and mentoring over the last six months to get my feet wet at least to the degree to roughly follow along. This time he gets into describing the tension between Kantian ethics and Consequentialist ethics (probably better known as Utilitarianism, which is more properly a subset of consequentialism) using the classic problem in philosophy that has been named the “Trolley Problem.”

The scenario of the Trolley Problem presents a dilemma: Do you decide to save one person at any cost, or do you decide, as the character Spock claimed to be the correct answer in the classic Star Trek television series, that, “The good of the many must outweigh the good of the few or the one.” The problem is faced in practical ways by every humanitarian and health mission in various ways daily, and needs to be faced head on, seeing the difficulty in the dilemma, and wrestling it out each time. In some ways, the project we are working on is an attempt to deal with the Trolley Problem—to assist in the development of an essential feature of public health infra-structure that supports both ends of the spectrum—being able to improve the general ability to provide public health for everyone at the same time that health can be improved for individuals.

Gayton is in his usual jovial mode, into the action, on-task, with a confidence of experience that allows for a friendly demeanor; he’s got a rare kind of intellect, comfortable in a wide range of topics and modulation from the esoteric to the practical. I’ve known Gayton for 10 years, though not well, introduced through a mutual friend in Canada, a forester turned ecologist that we both know and trust. Gayton worked with our friend Robin Clark because his background included work in Canadian tree planting camps; the set up is in bush conditions for the government-required replanting of areas that have been logged. As Gayton puts it, “I crab-walked sideways using my logistical skills to get into humanitarian aid work and MSF was kind enough to offer me an opportunity.” MSF is short for Medicínes Sans Frontiers, or, as we know it better in the English-speaking world, Doctors Without Borders. They won the Nobel Peace prize in 1999 for their work, and are partners in our current project, along with the British and American Red Cross. The project is being run under the auspices of the Humanitarian Open StreetMapTeam, we call it HOT for short.

MSF and the Red Cross are not the only partners in the WAMM project. Gayton, of course, has many connections after 13 years of experience for MSF including appointments as Head of Mission in some very difficult situations. He was in Haiti after the earthquake in 2010, and that experience formed some of the initial ideas for the adventure we are now engaged on. One of the problems in disaster situations is the danger of disease outbreak. Of course, calling it a “danger” is slightly euphemistic . . . it is more likely than not to happen because of the impact on sanitation and resources that inevitably follows. In Haiti, one of the main concerns was Cholera. The disease has a background environmental reservoir, (the disease exists, but does not usually come into contact with humans)—but when people do get exposed, when individuals become sick, the risk of more people getting sick from other people goes up 100 fold.

It is important to insert an aside here, particularly regarding the facts of the matter about the Cholera outbreak in Haiti. Though tropical Haiti is an ideal environment for Cholera, historically, it had been Cholera free. Haiti is surrounded by countries that are, relatively speaking, rich. They have historically dealt with any isolated cases quickly and efficiently. In Haiti, Cholera was actually introduced by UN peacekeepers through the dumping of raw sewage into the Artibonite river. Haitians noticed at the time, and complained vociferously, but the Nepalese ignored them. The United Nations is currently wanting to “wash its hands” of the situation, even though there is a pending case in a US Court. The MSF team wasn’t aware of this at the time, all they knew was that people were showing up at Triage with what soon proved to be Cholera.

Triage simply means “sorting.” In the western world, it is used to refer to primary, secondary, and tertiary care. Primary is something like a simple cut that needs a bandage; tertiary is admittance to a hospital. In crisis work medicine it refers to the designations Green, Red, and Black. Green means the patient will survive without immediate care, Red means that immediate treatment is necessary to save life, Black means that the decision will be made to not help; the person is beyond assistance, or, more wrenchingly, that the resources necessary to help them would leave insufficient resources for a larger number of those who can be saved. In a crisis situation the Consequentialist reality means that gut-wrenching decisions have to be made daily. MSF and other crisis response workers say that doctors working in the western world never need to do Triage—everyone is considered to be on the Red list, and resources are imagined to be infinite.

Map made by English Physician John Snow in 1854, showing point of origin for Cholera cases in the outbreak.

The story of how mapping is relevant to all of this is a fascinating one. One good place to begin is back in 1854 in London England, where there was also an outbreak of Cholera. English physician Dr. John Snow, riding the heady enthusiasm of the 19th century’s confidence in science and more sympathetic view to interdisciplinary approaches to problems that had its origin in the renaissance, decided to look at the outbreak mathematically, not primarily as a physician, who always want to be biased toward the individual (Kantian ethics), but to look at it from the perspective of helping the most people possible, (the Consequentialist position) realizing that some energy had to be spent on the source of the problem, otherwise more individual people would continue to become sick, and the supposed benefits of the strict Kantian position would become void. Snow wanted to find out where people lived—what was the possible commonality between them? That led to the creation of a map, and the foundation of modern public health care. It turned out that the map showed clearly a cluster of patient origin . . . and it wasn’t difficult then to realize that one of the water sources they shared, the “Broad Street Pump,” was a possible culprit. Snow locked up the water pump and stopped the Cholera epidemic in its tracks.